Erosive toe-web intertrigo: Clinical features and management.

BACKGROUND: Toe-web (TW) intertrigo is a common disease of fungal or bacterial origin. Gram-negative bacterial (GNB) TW intertrigo consists of weeping, erosive, painful lesions that may be recurrent, leading to functional disability. Eczema is often associated with this condition. The management of intertrigo is poorly codified. OBJECTIVE: To evaluate the efficacy and safety of a standardized treatment plan using topical steroids in relation to the course and the frequency of recurrence of GNB-TW intertrigo. METHODS: We conducted a prospective open interventional multicentre study from June 2020 to June 2021. Standardised treatment using TCS together with follow-up via phone calls were performed over a 6-month period. In addition, a retrospective historical monocentric study was performed for patients with suspected TW-GNB intertrigo treated without standardized management. The primary endpoint was disease duration. We performed a Wilcoxon test to compare the median duration of GNB-TW intertrigo in both series. RESULTS: We included 13 patients in the prospective cohort and 14 in the retrospective cohort. In both cohorts, most patients were male with a median age of 59 years. The most frequent signs were fissures and exudates. Eczema was often associated (51.8%). Identified risk factors were psoriasis, local humidity, fungal intertrigo, vascular disease (arterial or venous insufficiency), and a history of multiple local treatments prior to diagnosis. Pseudomonas aeruginosa was the predominant pathogen (48.1%). Median durations of TW-GNB intertrigo were 56 days and 61 days. There was no significant difference in the median duration of the disease between the prospective and the retrospective cohorts (respectively61 days and 56 days; p > 0.58). Relapses were more frequent in the retrospective cohort (respectively 7.7% and 21.4%). CONCLUSION: GNB-TW intertrigo is a difficult-to-treat disease often associated with eczema. While topical corticosteroids (TCS) seem to be an effective and well-tolerated treatment they do not appear to reduce disease duration compared to other treatments.

Antimold Prophylaxis May Reduce the Risk of Invasive Fusariosis in Hematologic Patients with Superficial Skin Lesions with Positive Culture for Fusarium.

Hematologic patients with superficial skin lesions on admission growing Fusarium spp. are at a high risk for developing invasive fusariosis during neutropenia. We evaluated the impact of primary prophylaxis with a mold-active azole in preventing invasive fusariosis in these patients. Between August 2008 and December 2014, patients with acute leukemia or aplastic anemia and recipients of hematopoietic cell transplants were screened on admission with dermatologic and direct exams and fungal cultures of superficial skin lesions. Until November 2009, no interventions were made. Beginning in December 2009, patients with baseline skin lesions and a direct exam and/or culture suggestive of the presence of Fusarium spp. received prophylaxis with voriconazole or posaconazole. Skin lesions in the extremities (mostly onychomycosis and interdigital intertrigo) were present on admission in 88 of 239 episodes (36.8%); 44 lesions had hyaline septate hyphae identified by direct exam, and cultures from 11 lesions grew Fusarium spp. Antimold prophylaxis was given for 20 episodes (voriconazole for 17 and posaconazole for 3). Invasive fusariosis was diagnosed in 14 episodes (5.8%). Among patients with baseline skin lesions with positive cultures for Fusarium spp., 4 of 5 without antimold prophylaxis developed invasive fusariosis versus 0 of 6 with antimold prophylaxis (P = 0.01; 95% confidence interval for the difference between proportions, 22% to 96%). Primary antifungal prophylaxis with an antimold azole may prevent the occurrence of invasive fusariosis in high-risk hematologic patients with superficial skin lesions on admission growing Fusarium spp.

Successful treatment of recalcitrant candidal intertrigo with Dr Michaels® (Fungatinex®) product family.

Candidal intertrigo is an infection of the skin caused by Candida albicans that typically occurs in opposing cutaneous or muco-cutaneous surfaces. Because Candidiasis requires a damaged and moist environment for infection, it typically occurs in areas of friction such as the skin folds of the body. Candidal intertrigo is often difficult to treat and results are often unsatisfactory. In addition, there is a lack of evidence-based literature supporting prevention and treatments for candidal intertrigo. The aim of the study was to evaluate the efficacy of Dr Michaels® (also branded as Fungatinex®) products in the treatment of fungal intertrigo, in 20 women and 2 men with a mean age of 72. Five patients (3 female and 2 male) had type 2 diabetes and 16 (14 female and 2 male) were obese. The patients were treated with Dr Michaels® (Fungatinex®) moisturising bar, topical ointment (twice daily application) and oral herbal formulation, PSC 200 two tablets twice daily with food. After 2 weeks of treatment, the lesions had mostly resolved in all patients with only slight erythema evident. After six weeks of treatment using the moisturising bar, topical ointment and oral herbal formulations from the Dr Michaels® (Fungatinex®) product family, the lesions had totally resolved in 18 patients, while 4 patients had to continue the therapeutic protocol for another 2 weeks. Our results demonstrate that the Dr Michaels® (Fungatinex®) complementary product family is efficacious in the treatment of recalcitrant candidal intertrigo. Furthermore, this study highlights that the Dr Michaels® (Fungatinex®) product family is fast-acting and well tolerated with no serious adverse events reported. These data have important implications for resistant cases of candidal intertrigo where traditional therapies have failed.

Intertrigo and secondary skin infections.

Intertrigo is a superficial inflammatory dermatitis occurring on two closely opposed skin surfaces as a result of moisture, friction, and lack of ventilation. Bodily secretions, including perspiration, urine, and feces, often exacerbate skin inflammation. Physical examination of skin folds reveals regions of erythema with peripheral scaling. Excessive friction and inflammation can cause skin breakdown and create an entry point for secondary fungal and bacterial infections, such as Candida, group A beta-hemolytic streptococcus, and Corynebacterium minutissimum. Candidal intertrigo is commonly diagnosed clinically, based on the characteristic appearance of satellite lesions. Diagnosis may be confirmed using a potassium hydroxide preparation. Resistant cases require oral fluconazole therapy. Bacterial superinfections may be identified with bacterial culture or Wood lamp examination. Fungal lesions are treated with topical nystatin, clotrimazole, ketoconazole, oxiconazole, or econazole. Secondary streptococcal infections are treated with topical mupirocin or oral penicillin. Corynebacterium infections are treated with oral erythromycin.

Rapid relief of intertrigo-associated pruritus due to Candida albicans with isoconazole nitrate and diflucortolone valerate combination therapy.

A 43-year-old male, with intertrigo due to Candida albicans located at the inguinal folds and accompanied by severe pruritus, was treated with topical 1% isoconazole nitrate and 0.1% diflucortolone valerate (2 applications/day for 7 days). An improvement of pruritus was reported 2 days after the beginning of the treatment. Skin lesions improved after 3 days of treatment. Complete remission of both skin lesions and pruritus was observed at day 7. No side effects were observed.

Greenish-blue staining of underclothing due to Pseudomonas aeruginosa infection of intertriginous dermatitis.

Intertrigo (intertriginous dermatitis) is an inflammatory condition of the skin folds, induced or aggravated by heat, moisture, maceration, friction, and lack of air circulation. Intertrigo can become secondarily infected. Three cases of intertrigo are described herein which presented with greenish-blue staining of underclothing. Cultures revealed Pseudomonas aeruginosa which is a gram-negative aerobic bacillus that produces the pigments pyocyanin and pyoverdin that responsible for this characteristic hue. All three patients responded to a course of oral ciprofloxacin with resolution of the intertriginous dermatitis. Therefore, greenish-blue staining of clothing is an important indicator for pseudomonal intertrigo.

[Endogenous endophthalmitis as a complication in erysipelas]. / Endophtalmie endogène compliquant un érysipèle.

BACKGROUND: Endogenous endophthalmitis is a devastating infection of the eye that leads to blindness in about two-thirds of patients. It results from the haematogenous spread of a microorganism from a focus of sepsis, mainly gastro-intestinal, genitourinary or cardiac. PATIENTS AND METHODS: We describe the case of a diabetic subject presenting endogenous endophthalmitis following erysipelas of the leg due to Streptococcus agalactiae. The outcome was favourable thanks to prompt initiation of appropriate antibiotic treatment. DISCUSSION: Endogenous endophthalmitis as a complication of a skin infection is a rare entity, with only about 30 reported cases in the literature. Awareness of this condition among dermatologists would allow prompt intervention, which is essential for sparing of the patient's eyesight.

A randomized controlled trial to compare the effectiveness and safety of adsorbent lotion containing tapioca starch, spent grain wax, Butyrospermum parkii extract, argania spinosa kernel oil, aloe barbadensis, rosehip oil, and allantoin with a low-potency topical corticosteroid in the treatment of intertrigo.

BACKGROUND: Intertrigo is an inflammatory skin-fold condition. Candida infections may occur concurrently or afterward. Topical corticosteroids may reduce inflammation but exacerbate Candida infections. The treatment is contentious. OBJECTIVE: To evaluate the efficacies and safety of adsorbent lotion containing tapioca starch, spent grain wax, Butyrospermum parkii extract, argania spinosa kernel oil, aloe barbadensis, rosehip oil, and allantoin for the treatment of mild-to-moderate intertrigo, relative to 1% hydrocortisone cream. METHODS: This randomized, double-blinded study enrolled 40 intertrigo patients. Twice daily, 20 patients applied adsorbent lotion while the remainder used 1% hydrocortisone cream. Efficacy evaluation, skin biophysical measurements, skin tolerability, safety, and visual analog scale (VAS) patient-satisfaction scores were evaluated at baseline and Week 2. RESULTS: The adsorbent lotion showed higher complete cure rates for color, partial epidermal loss, papules/pustules/vesicles/patches, dryness, and scaling than the corticosteroid without statistical significance. Adsorbent lotion demonstrated significantly higher reduction in pruritus than the corticosteroid treatment. Reduction of erythema level using Mexameter and VAS patient-satisfaction scores were not statistically different between adsorbent lotion and hydrocortisone cream. No adverse effects or superimposed infections were reported. CONCLUSIONS: The anti-inflammatory efficacies of adsorbent lotion and low-potency steroid were equivalent. The lotion was safe and produced excellent pruritus reduction. Patient satisfaction was high.

Intertriginous pattern of toxic erythema of chemotherapy.

Chemotherapeutic agents may induce both local and systemic cutaneous toxicity, and evaluation of these reactions in oncologic patients constitutes a real challenge. The authors describe a 78-year-old Caucasian woman, with a past medical history relevant for right radical mastectomy with axillary dissection because of stage 2 breast invasive ductal carcinoma (T2N3M0), referred to our department because of an intertriginous eruption in her groin. Two weeks before the eruption, a chemotherapy regime with cyclophosphamide, methotrexate, and 5-fluorouracil was performed. Examination revealed erythematous and dusky violaceous papules coalescing into edematous patches in the inguinal intertriginous area, including the internal surface of her thighs, groin, genital area, and intergluteal cleft. Skin cultures for bacteria and fungus were negative. Clinical and histological data were consistent with an intertriginous pattern of toxic erythema of chemotherapy (TEC). Oral prednisolone therapy (0.5 mg/kg) was started, tapered over a 1-week period, and along with general measures that included topical zinc oxide suspension, cutaneous lesions cleared completely within the first days. Although patient reassurance, she refused any kind of new chemotherapy infusions. Due to their high metabolic rate, the skin, mucous membranes, and annexes are one of the most important target organs of the toxicity associated with systemic chemotherapy. Several patterns of cutaneous eruptions to chemotherapy have been reported in the literature. Trying to resolve this issue, recently recommended was a new clinically descriptive term, TEC, in order to emphasize the overlapping features of these entities. Early recognition of this entity is critical, not just from a prognostic standpoint, but also to avoid unnecessary, potentially harmful therapeutic interventions.

A novel treatment of intertrigo in athletes and overweight subjects.

BACKGROUND: Intertrigo is a recurrent inflammatory dermatosis involving large/small body folds. Skin barrier products represent the mainstay of treatment in uncomplicated mild/moderate intertrigo. AIMS: To assess by clinical and instrumental evaluation the efficacy and tolerability of a new barrier spray containing zinc gluconate-taurine complex and zinc oxide combined with panthenol, glycerin, and Shea (Butyrospermum parkii) butter in mild-to-moderate intertrigo in athletes and overweight subjects. METHODS: In this open-label prospective trial, 20 adult patients, with mild/moderate intertrigo enrolled at the Dermatology University Clinic of Catania (Italy), were instructed to apply the spray twice daily for 30 days. Degree of erythema was performed clinically and by polarized dermoscopy using a 5-point severity scale (from 0=no erythema to 4=severe erythema) at baseline, and at 15 and 30 days. The measurement of pruritus was carried out by a subject-completed visual analog scale (VAS) (from 0 mm=no pruritus to 100 mm=severe pruritus), at all time points. An Investigator Global Assessment (IGA) using a 6-point scale (from -1=worsening to 4=complete response/clear) was also conducted at 30 days, along with a self-administered tolerability questionnaire. Statistical analysis was performed using SAS version 9. RESULTS: At 15 days, a statically significant reduction from baseline in erythema severity (mean from 3.4 ± 0.3 to 2.5 ± 0.2) along with pruritus intensity (mean from 70 ± 15.4 mm to 40 ± 9.5 mm) was observed. At 30 days, all evaluated parameters showed a further progressive statistically significant reduction from baseline. No relevant side effects were recorded. CONCLUSIONS: Our results suggest that the tested spay containing antiseptic/anti-inflammatory and anti-irritation agents may represent a valid therapeutic option for mild/moderate intertrigo.

Medical honey for canine nasal intertrigo: A randomized, blinded, placebo-controlled, adaptive clinical trial to support antimicrobial stewardship in veterinary dermatology.

Intertrigo is a skin fold dermatitis often requiring recurrent treatment with topical antiseptics or antibiotics, which can select antimicrobial resistance. To minimize this risk, we tested the effectiveness of medical-grade Manuka honey at treating intertrigo as compared to a placebo hydrogel. We additionally characterized the culturable microbial flora of intertrigo and recorded any adverse effect with either treatment. During this randomized, placebo-controlled, double-blinded, adaptive group-sequential trial, the owners washed the affected sites on their dog with water, dried and applied a thin film of either the honey or the placebo product once daily for 21 days. Cytological and lesional composite scores, owner-assessed pruritus, and microbial cultures were assessed prior to treatment and on Day-22. The fixed effects of time, treatment, and animal-related variables on the pruritus and on each composite score, accounting for random dog effect, were estimated separately with generalized linear mixed models for repeated count outcomes (α = 0.05). The null hypothesis of equal treatment effects was rejected at the first interim analysis. The placebo (n = 16 dogs) outperformed the medical honey (n = 13 dogs) at improving both the cytological score (Treatment×Time = -0.35±0.17; P = 0.04) and clinical score (Treatment×Time = -0.28±0.13; P = 0.04). A microbial burden score higher than 4 increased the severity of the cytological score (dichotomous score: 0.29±0.11; P = 0.01), which in turn increased the severity of the clinical score and pruritus score. For every unit increase in cytological score, the linear predictor of clinical score increased by 0.042±0.019 (P = 0.03), and the one of pruritus score increased by 0.12±0.05 (P = 0.01). However, medical honey outperformed the placebo at alleviating the dog's owner-assessed pruritus after statistically controlling for masking effects (Time = -0.94±0.24; P = 0.002; and Treatment×Time = 0.80±0.36; P = 0.04). Unilateral tests of the least-square mean estimates revealed that honey only significantly improved the pruritus (Hommel-adjusted P = 0.003), while the placebo only improved the cytological and clinical scores (Hommel-adjusted P = 0.01 and 0.002, respectively). Taken together, these results question the value of Manuka honey at treating nasal intertrigo in dogs.

Symmetrical drug-related intertriginous and flexural exanthema due to clindamycin.

Systemic drug exposure can produce a skin reaction consisting of symmetrical erythema involving the gluteal and intertriginous areas in the absence of systemic involvement. Symmetrical drug-related intertriginous and flexural exanthema (SDRIFE) occurs after systemic exposure to a drug in which the patient was not previously sensitised, either in the first dose or after several doses. The mechanism of SDRIFE is unknown but is hypothesised to be the result of a delayed hypersensitivity response resulting in a cutaneous eruption some days after the exposure to the drug. The diagnosis should be clinical, based on the history and examination, but skin tests can also be performed to confirm sensitisation. But, as always, the gold-standard test is oral provocation. It is important to know this clinical entity to prevent re-exposure to the responsible allergen in the future.

Case of severe bullous erythema including intertrigo-like eruptions with angioedema induced by pegylated liposomal doxorubicin.

Pegylated liposomal doxorubicin (PLD) is an anthracycline anticancer agent used in ovarian cancer and a form of doxorubicin enclosed in pegylated liposomes. There are only a few reports on intertrigo-like eruptions caused by PLD. We describe the first case of severe bullous erythema, including intertrigo-like eruptions with angioedema, induced by PLD in Japan. We present the case of a 53-year-old woman who was diagnosed with stage IIIC ovarian cancer. After receiving three cycles of PLD, the patient developed swelling of the upper lip and painful erythema with blisters and erosions on the axilla, upper back, flank and wrists. The patient was diagnosed with angioedema and severe skin lesions, including intertrigo-like eruptions induced by PLD. Although treatment with oral prednisolone and topical steroids was effective against these eruptions, the administration of PLD was discontinued because of its ineffectiveness against the primary disease. Several risk factors, such as obesity, perspiration and racial differences, may contribute toward a severe manifestation such as that seen in our patient. Moreover, our case was the first accompanied by angioedema. The mechanism of coexistence of intertrigo-like eruptions and angioedema is not clear; further studies are required to clarify the pathological mechanism of intertrigo-like eruptions.